Cabarrus_Well Abandonment_20241014

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.1.Well Contractor Information: WELL ABANDONMENT DETAILS .
Pijiint F gki 7a.For Geoprobe/DPT or Closed Loop Geothermal Wells having the same
Well Contractor Name(or well ouster personally abandoning well on his/her property) well construction/depth,only 1 GW1 3 i is needed. Indicate TOTAL NUMBER of
• ��, l — c wells abandoned:
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- NC Well Contractor Certification Number 7b.Approximate volume of waterremaining in well(s): Li •9 (gal.)
Morgan Well & Pump,v I N C FOR WATER SUPPLY WELLS(ONLY:
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Company Name granulated chlorine •
a I [� I 7c.Type of disinfectant used:
2.Well Construction Permit#: C t11 -VV lx&-1.-ao la- -
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.)if known .
7d.Amount of disinfectant used: 1.
3.Well use(check well use): •
Water Supply Well: 7e.Sealing materials used(check all that apply):.
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout dBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Isidential Water Supply(single) 0 Sand Cement•Grout O.Dry Clay'
❑lndustrial/Commercial ❑Residential Water Supply(shared). ❑ Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel .
Non-Water Supply Well: • '❑ Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ,i`` ";,'❑I2pcouery -
Injection Well: ".^ ,.,✓1...., :;r L.L., • 7f.For each material selected above,provide amount of materials used:
. ❑Aquifer Recharge 0 r T ` U9 undwater Remediation I_ AA
❑Aquifer Storage and Recovery ❑Salty Barrier .
❑Aquifer Test Irf,:,.,tn,l'.f;. 7.1,r..-...z.vorS.t.tntWAerDrainage
❑Experimental Technology D;'"•u''E'a:i Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer , A I
OGeothetmal(Heating/Cooling Return) ❑Other(explain under 7g) (� led 0 V god if f p!! 0 .
4.Date well(s)abandoned: "Ie-� ! ra q c�S to ` f i 4e &n4
5a.Well location: .
• Facility/Owner Name Facility lD#(if applicable) 8.Certification:
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(A)C661l1ayen PI MAT 4 c, . I! i.:(1 .-074,
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Physical Address,City,and Zip " Signature of Certified Well Contractor or Well Owner Date'
Cabarws . By Signing:thip font,I hereby certij5)that the well(s) was(were) abandoned in •
County , . Parcel Identification No..(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to-the well owner.
5b.Latitude and longitude in•degrees/minutes/seconds or decimal degrees:
(if well field,one/lat/long is sufficient) • 9.Site diagram or.additional well details: •
36. 1 v� �1• N S(6'• �Q-5 l W You may use the back of this page to provide additional well site details or well
Ll V abandonment details.- You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS •
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells •
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ONLY with the same construction/abandonment,you can submit one form.
10a.For All•Wells: Submit this form within 30 days of completion of well
6a.Well ID#: • •• • abandonment to the following:
'• : • - • -'Division of Water Resources,Information Processing Unit,
•6b.Tofal well=deXrth ( Q• (ft.) • 1617 Mail Service Center,Raleigh,NC 27699-1617
- lOb.For Injection Wells: In addition to•sending the form to the address in l0a
. 6c.Borehole diameter: Z• i . .(in.) above, also submit one copy of this form within 30 days of completion of well .
. abandonment to the following: ii'
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6d.Water level below ground surface: O • (ft) . ' Division of'Water.Resources,Underground Injection Control Program, .
1636 Mail Service Cente•r;Raleigh,NC 27699=1636 .
6e.Outer casing length(if known): 1111: at.) IOc.For Water Sup &c•Iniectio ply n Wells: In addition to sending the form to the
address(es).above,also submit one copy of this form within 30 days of completion
N .of well abandonment to the county health department of the county where'
6f.Inner casing/tubiing length(if known): 1' (ft) abandoned
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6g.Screen length'(if known): x (ft) •
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources•-, i.-. • Revised 2-22-2016